Does
Chest X-Ray Finding Affect The Decision of Performing
Bronchoscopy in A Case of Foreign Body Aspiration
in Children?
.........................................................................................................................
Dr. Walid Issa Treef. MD, JPSB
King Hussein Medical Center, Department of General
Surgery.
Pediatric Surgery Division, Amman Jordan
Correspondence
to:
DR. Walid I. Treef
PO Box 141001
Bayader Wadi-Essir 11814
Jordan
E-mail: walid_6@yahoo.com
.........................................................................................................................
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ABSTRACT
Aim
Is to point
out whether chest X-ray in cases of history
of foreign body aspiration of non-radio
opaque objects affect the decision of
performing bronchoscopy or not.
Patients
and Methods
This
prospective study - the role of chest
X-ray in diagnosis of non-radio opaque
foreign body inhalation- in the tracheobroncheal
tree, was carried out in the pediatric
surgery unit at King Hussein Medical Center
(KHMC), Amman, Jordan.
The
patients were referred from different
hospitals in Jordan to the pediatric surgery
unit between 28/4/2004 and 17/10/2006,
with a history of foreign body aspiration.
Upon
admission patients were divided into groups
according to the age and time from the
incidence of foreign body aspiration,
till admission to our hospital. Chest
X-ray and complete blood count were performed
in every patient.
Results
Out
of 63 patients in this study, 38 (60%)
were males and 25 (40%) were females.
Age ranged between 8 months and 11 years
with a mean of 27 months; 44 (70%) patients
were under the age of 3 years.
Chest
radiograph was normal in 22 (35%) patients.
The most common abnormal finding was hyperinflation
of the lung which was seen in 38 (60%)
of patients. Atelectasis was seen in three
patients, while consolidation was seen
in one patient. One patient was found
to have congenital diaphragmatic hernia.
Conclusion
We
believe that with the history of foreign
body aspiration, clinical findings are
a corner stone in diagnosis. Chest X-ray
can help in diagnosis and localization
the site of the foreign body, but does
not affect the decision of performing
bronchscopy.
Key
words: foreign body, aspiration, childhood.
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A foreign body in the tracheobroncheal
tree is usually encountered in the pediatric
age group. In developing countries it is very
common and it is a serious condition. Foreign
body aspiration is the cause of death for more
than 300 children per year in the United States.(1,2,3,4)
Foreign body aspiration can cause sudden death
in some cases or may lead to chronic lung problems,
and these patients are frequently misdiagnosed
and treated for pneumonia or asthma.(5)
An adequate and prompt treatment is associated
with very low mortality. Patients with an inhaled
foreign body offer a diagnostic challenge to
physicians.
Physicians generally adopt an attitude of urgency
regarding the removal of aspirated foreign bodies,
partly because aspiration has been blamed for
a large number of deaths; however the current
mortality rate from foreign body inhalation
is between 0% and 1.8% according to various
studies.(3)
The aim of this study is to point out whether
chest X-ray in case of history of foreign body
aspiration of non-radio opaque objects affect
the decision of performing bronchoscopy or not.
This prospective study; of
the role of chest X-ray in diagnosis of non-radio
opaque foreign body inhalation, in the tracheobroncheal
tree was carried out in the pediatric surgery
unit at King Hussein Medical Center (KHMC),
Amman, Jordan.
King Hussein Medical Center is the largest
hospital in Jordan with a capacity of 1000 beds;
it contains all branches of surgery and medicine.
The patients, were referred from different
hospitals in Jordan to the pediatric surgery
unit between 28/4/2004 and 17/10/2006, with
a history of foreign body aspiration. The mean
age of the patients was 27 months with a range
of eight months to 11years.
Upon admission patients were divided into groups
according to the age and time from the incidence
of foreign body aspiration till admission to
our hospital.
Chest X-ray and complete blood count were performed
in every patient. The foreign body was removed
under general anesthesia with controlled ventilation
and with surface oxymetry after an adequate
fasting interval in the operating room.
All foreign bodies were retrieved using a rigid
bronchoscope, and this was performed by a pediatric
surgeon. The chest X-ray was seen and reported
by a senior radiologist.
Out of 63 patients in this study, 38 (60%)
males and 25 (40%) were females. Age ranged
between 8 months and 11 years with a mean of
27 months; 44 (70%) patients were under the
age of 3 years.
Chest radiograph was normal in 22 (35%) of
patients. The most common abnormal finding was
hyperinflation of the lung which was seen in
38 (60%) patients; 24(38%) patients had hyperinflation
of the right lung, while in 14(22%) patients
had hyperinflation of the left lung. Atelectasis
was seen in three patients, while consolidation
was seen in one patient. One patient was found
to have a congenital diaphragmatic hernia.
|
Table
1. Patients
with normal chest X-ray on admission |
|
Age group |
Time from aspiration to admission |
Bronchoscopy findings |
|
12hours< |
12-24 hours |
> 24 hours |
|
1year < |
- |
1 |
1 |
Positive in 2
|
|
1-3 years |
2 |
5 |
8 |
Positive in 13
|
|
3-5years |
1 |
- |
- |
Positive in 1
|
|
5-7years |
- |
- |
2 |
Positive in 2
|
|
7-9years |
1 |
- |
- |
Positive in 1
|
|
9-11years |
|
- |
1 |
Positive in 0
|
|
Total |
4 |
6 |
12 |
Positive in 19
|
The most common clinical finding was decreased
air entry over the affected site. The type of
aspirated foreign body is shown in Table 2.
|
Table
2. Type
of foreign body extracted |
|
Foreign Body Extracted |
Number
|
|
Peanut
|
28(45%)
|
|
Melon seed
|
10(16%)
|
|
Sunflower seed
|
6(10%)
|
|
Food particles (apple, carrot, cucumber
etc)
|
10(16%)
|
|
Almond
|
5(8%)
|
|
Plastic pen cover
|
3(5%)
|
Indirect radiological findings suggestive of
foreign body aspiration were found in 41 (65%)
patients, and indicated the site of the foreign
body in 38 (60%) patients.
Foreign body inhalation
is a life threatening condition in young children.
It is more common in small children and infants;
the anatomic relation of the larynx, shouting,
playing, crying and playing while eating and
sometimes lack of parental supervision contributes
to this hazard(6).
Aspirated foreign body can lead to asphyxia,
post-obstructive pneumonia, granuloma, bronchectasis,
atelectasis, and chronic cough, when the foreign
body was inhaled into the distal bronchial system
without causing an acute obstruction. It may
remain silent for a while depending on its nature,
therefore early diagnosis and removal of the
foreign body is recommended. Nevertheless risks
of both flexible and rigid bronchoscopy are
low.
Chest X-rays are frequently used in assessment
of patients with respiratory complaints, and
it is an important tool for diagnosis of foreign
body inhalation especially when we are dealing
with radio-opaque foreign bodies. In this study
all patients had non radio opaque foreign bodies;
so indirect signs of air trapping, atalectasis
due to partial obstruction, consolidation and
shift of the mediastenum can occur.
Radiological findings depend on the size, type,
location and time from the incidence of inhalation
till diagnosis.
Hyperinflation of the lung was seen in 38 (60%)
of patients; 24 (38%) patients had hyperinflation
of the right lung, while in 14 (22%) patients
hyperinflation occurred in the left lung.
In this study normal chest X-ray was found in
22 (35%) patients, nevertheless 20 patients
had positive bronchoscopy. These results are
comparable with what had been published in the
literature(6,7,11).
The majority of normal chest X-ray was seen
in the second age group, and mostly when the
inhalation time was more than 24 hours. This
is due to the fact that 44 (70%) patients were
under the age of 3 years and most of the foreign
bodies were organic food materials in nature,
and need time to swell and cause obstruction.
The predominance of non-radio opaque foreign
body inhalation, recommends special attention
to indirect radiological alteration. The hyperinflation
was the commonest radiological sign in this
study. It occurred in 60% of our patients; this
result is comparable with that written in the
literature.
The chest X-ray was able to reveal the indirect
radiological findings suggestive of foreign
body inhalation in 65%; moreover it was in 60%
useful in indicating the site of foreign body
before bronchoscopy was performed. Svedstrom
et al; reported 67% positive chest X-ray in
bronchoscopy with proven tracheobroncheal foreign
body(8,9,10).
Other diagnostic modalities have been recommended,
including ventilation-perfusion scans, and magnetic
resonance imaging.
We did not use any of these in our patients,
because we believe that the history of foreign
body aspiration, and clinical findings are a
corner stone in diagnosis. Chest X-ray can help
in diagnosis and localization the site of the
foreign body, but does not affect the decision
for performing bronchoscopy.
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- Benjamin B. Vandeleur T: Inhaled foreign
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Leigh C. McGill, and Kenneth J. Pippus:
Foreign Body Aspiration in Children: Value
of Radiography and Complications of Bronchoscopy.
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- Llyas Bader, Amjad ch et al. tracheobronchialforeign
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